Thinking beyond the Joint Commission for patient safety

A Proactive Culture

One of the most frustrating perceptions, I think, is the one held by staff in the healthcare field, who often think the safety initiatives that hospitals put in place are for compliance with The Joint Commission. If I am on the nursing unit or out in the ambulatory setting doing patient safety rounds, I hear comments like “Are we due for a survey?” or “Did we do something wrong?”

Hospitals need to move from that culture of  “We check because we did something wrong and are in trouble”, to a culture of  “we need to be proactive and transparent about potential breakdowns in processes that could cause patient harm”.

The Joint Commission recognition “gold seal of approval” is important, yes. Having your hospital accredited by The Joint Commission is voluntary and a great deal of effort needs to take place to ensure you are compliant with their standards.

If Compliance Wasn’t An Issue…

But think about what a hospital might do if they decided to stop having Joint Commission survey them or if the hospital is excelling in terms of compliance. Would they stop looking at ways to improve patient safety?

I doubt it.

First, The Joint Commission standards do make sense and by complying with them, hospitals do more good than harm to the patient. If something is working, why stop it?

In the hospital, there are hundreds of processes and systems that link together to keep all things going. There are house wide systems, and within departments, there are systems. We design the systems and they get tested when we are doing the work on a day-to-day basis. The Joint Commission surveys consist of “tracers”, which follow the patient through our hospital systems.

The Tracer Methodology

The patient comes in through the ED and has a CT scan. The patient has an allergic reaction to the dye. They look at screening for allergies and how that is communicated at hand off. Hand off is a national patient safety goal. The surveyor might ask the nurse to explain what method/model is used for handoff. The nurse might say SBAR. The surveyor might ask the nurse about the organization’s policy on SBAR. The nurse might say yes. The surveyor would then ask to see it. The nurse would need to retrieve that policy right away. If the nurse has difficulty finding it, the surveyor would pick up on that and investigate the policy and procedure systems in place.

If you are not having Joint Commission surveys or really feel you have excellent tracer activity, what do you do? You look at high risk, low volume, problem-prone activities, and look at those processes. Then, you pull your policies on those topics. Do you have policies that are current? Use your policy and procedure management system to review, revise and archive policies so that they are loaded and easily accessible. Ensure that you communicate to staff any changes made to content and then educate them on changes in processes and systems. It is unfair to staff to make changes and just put the policy on line without disseminating that change to staff.

When it comes to survey time – it will be obvious to the surveyor when staff are doing things in different ways than stated in the policies.

If you are a high reliability organization however, you will be out on the floors looking at these issues regularly and at the same time, helping to change the culture of patient safety.

Best,

Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical

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